Healthcare Provider Details

I. General information

NPI: 1083534044
Provider Name (Legal Business Name): JEREMY DANIEL OH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 GREEN BAY RD
NORTH CHICAGO IL
60064-3048
US

IV. Provider business mailing address

30039 N WAUKEGAN RD APT 107
LAKE BLUFF IL
60044-5401
US

V. Phone/Fax

Practice location:
  • Phone: 909-786-6281
  • Fax: 224-610-4846
Mailing address:
  • Phone: 909-786-6281
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number113514
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: